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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7/ 7 <br /> OWNER/OPERATOR <br /> %a— 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME vU J ovyv eu <br /> SITE ADDRESS • <br /> C(�" Street Number Direction Street Na , J Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> ITY STATE <br /> PHONE#1 EXT APN# LAND USE APPLICATION# S J <br /> (201 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� 'W u CHECK if BILLING ADDRESS <br /> BUSINESS NAME G P NE E.T. <br /> S - o i <br /> HOME,pr MAILING ADDRESS FAX# <br /> CITY STATE CA ZIP Ct <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � , Y t- I } C DATE: C / c- I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGERS OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,pro0 of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me or <br /> my representative. AA VA <br /> TYPE OF SERVICE REQUESTED: R1911Z IVE <br /> COMMENTS: <br /> � 5 aR <br /> - 32015 <br /> sa,v� <br /> HEJI <br /> q N�R <br /> EPA gLNTy. <br /> TME <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (ifalrea completed: SERVICE CODE: PIE: <br /> Fee Amount: ( C,U Amount P Payment Date 3//`"S— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />